It is now well known that engaging in light to moderate physical activity on a regular basis is of significant value for most people that have either Type 1 or Type 2 diabetes. In fact the American Diabetes Association recommends that people with diabetes should get a minimum of 150 minutes of light to moderate exercise per week including aerobic and resistance training.
What the ADA says...
It has also been recommended that people with peripheral diabetic neuropathy that have reduced or absent feeling in their feet should not engage in any form of weight bearing exercise activity. The American Diabetes Association recommends that people with diabetes-related peripheral neuropathy should limit the amount of weight-bearing physical activity they perform due to their increased risk of foot ulcers and amputation (1, 2). This is based on the fact that with peripheral neuropathy there is either a decreased ability or total inability in the feet to feel pain or discomfort.
As an example, standing barefoot on hot asphalt maybe in a parking lot in the middle of the summer would be very uncomfortable for someone with normal sensation in their feet, however go unnoticed for someone with peripheral neuropathy. Similarly, the person with peripheral neuropathy may develop a painful nickel-sized blister after walking too far or when wearing new shoes and not even feel it. Without daily inspection of the ankles and feet (which a lot of people do not do) this blister could go unnoticed for days resulting in a potentially infected, slow to heal, or non-healing wound. In the worst case this could lead to an amputation. All of this is the result of losing what is called the protective sensation in the feet.
In the absence of peripheral neuropathy whenever there is insult to the foot or feet such as a blister, a cut or scrape or stepping on a small piece of glass or nail, there would be pain which would cause you to notice the injury and hopefully treat the wound accordingly.
There are also painful stages of neuropathy that can precede lack of sensation which are characterized by frequent but intermittent pain in the feet throughout the day, having pain only in the evening while in bed to constant pain. This stage of neuropathy can result in changing the way you walk, that is your stride length, which part of your feet you strike the ground with first and ultimately what part of your feet support your body weight.
Because of everything I have just mentioned above this leads to the unfortunately recommendation that discourages walking for a great many people with diabetes.
To Walk or Not to Walk?
So where does that leave us? Exercise is arguably the best treatment there is, particularly in controlling Type 2 diabetes, and preventing diabetes related complications, such as peripheral neuropathy, however once you have peripheral neuropathy in your feet you should avoid doing any weight bearing exercise.
I have wrestled with the dilemma for years about how to guide my patients that would benefit immensely from starting to exercise or increasing their exercise however have various stages of neuropathy.
According to the Centers for Disease Control and Prevention, from 2000-2002, approximately 60 percent of lower-extremity amputations in the United States were diabetes-related, with the majority of those amputations being preceded by a foot ulcer (3). Almost all diabetic foot ulcers occur in those people that have lost feeling in their feet due to diabetic peripheral neuropathy (4, 5).
On the other hand poorly controlled blood glucose control contributes greatly to peripheral neuropathy.
Eight-year cardiovascular mortality is 34 percent lower among people with diabetes who walk two hours per week compared with non-walkers (6).
Feet First Randomized Controlled Trial
The Feet First Randomized Controlled Trial was designed to look at the effect of weight-bearing activity on foot ulcer incidence in people with diabetic peripheral neuropathy. The study, conducted over a 12-month period by Lemaster and colleagues, showed that participants in the Feet First intervention group achieved a modest increase in activity, with no increase in foot lesions, compared with those in the control group. The group also recommended additional research be conducted in this area to investigate the current guidelines and close supervision for patients with diabetes and peripheral neuropathy (7).
Tuttle and colleagues found that people with Type 2 diabetes and peripheral neuropathy experienced no negative consequences when performing moderate-intensity, weight-bearing exercise in their study (2).
Dr. Sheri Colberg reports in her article "Exercising with Peripheral Neuropathy" that recent descriptive studies suggest that patients with a lack of feeling in their feet who participate in daily weight-bearing activity are at decreased risk of foot ulceration compared with those who are less active (8, 9), especially if their daily routine is very similar with little variation from day to day regarding their physical activity (9, 10).
As a result of the above information, I am going to continue evaluating each of my class participants on a case by case basis, however, for those patients with peripheral neuropathy that I believe will be prudent in checking their feet and following the recommended foot care guidelines and stand to gain significant benefit from performing some weight bearing exercise, I will be more likely to recommend it to them.
1. Singh, N., D. G. Armstrong, and B. A. Lipsky: Preventing foot ulcers in patients with diabetes. JAMA 293 (2):217-228, 2005
2. Tuttle, L. J., M. K. Hastings, and M. J. Mueller: A moderate-intensity weight-bearing exercise program for a person with Type 2 diabetes and peripheral neuropathy. Phys Ther 92 (1):133-141, 2012
3. Centers for Disease Control and Prevention. History of foot ulcer among persons with diabetes -- United States, 2000-2002. MMWR. 2003;52:1098-1102. Medline
4. Pham H, Armstrong DG, Harvey C, et al. Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care. 2000;23:606-611.
5. Reiber GE, Smith DG, Wallace C, et al. Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. JAMA. 2002;287:2552-2558. CrossRefMedline
6. Gregg EW, Gerzoff RB, Caspersen CJ, et al. Relationship of walking to mortality among US adults with diabetes. Arch Intern Med. 2003;163:1440-1447. CrossRefMedline
7. Lemaster, J. W., M. J. Mueller, G. E. Reiber, D. R. Mehr, R. W. Madsen, and V. S. Conn: Effect of weight-bearing activity on foot ulcer incidence in people with diabetic peripheral neuropathy: feet first randomized controlled trial. Phys Ther 88 (11):1385-1398, 2008
8. Richerson, S., and K. Rosendale: Does tai chi improve plantar sensory ability? A pilot study. Diabetes Tech Ther 9(3):276-286, 2007
9. Ko, S. U., S. Stenholm, C. W. Chia, E. M. Simonsick, and L. Ferrucci: Gait pattern alterations in older adults associated with type 2 diabetes in the absence of peripheral neuropathy--results from the Baltimore Longitudinal Study of Aging. Gait Posture 34 (4):548-552, 2011
10. Kanade, R. V., R. W. van Deursen, K. Harding, and P. Price: Walking performance in people with diabetic neuropathy: benefits and threats. Diabetologia 49 (8):1747-1754, 2006
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